Endoscopic Variceal Obturation and Retrograde Transvenous Obliteration

Introduction

Bleeding from the esophagus, duodenum, and stomach is called acute upper gastrointestinal bleeding. The dilated veins are found in the stomach lining, known as gastric varices.

Gastrointestinal bleeding is called cardio fundal varices based on its location. Gastric varices in the cardio-fundus region have more vascular supply due to the multiple veins in the area. Hence, bleeding from the cardio-fundus part is challenging to manage. These gastric varices are mainly due to portal hypertension. Cirrhosis causes at least 90 percent of portal hypertension in adults. The average hepatic venous pressure gradient is five to six milligrams of mercury (mm Hg). Clinically significant portal hypertension is present when the angle exceeds 10 mm Hg and the risk of variceal bleeding increases beyond a gradient of 12 mm Hg. Acute gastric cardiofundal variceal bleeding is diagnosed by endoscopy. Endoscopic variceal obturation (EVO) and retrograde transvenous obliteration (RTO) treatment have recently helped control acute gastric cardiofundal variceal bleeding.

What Is Liver Cirrhosis?

Cirrhosis is diffuse hepatic fibrosis and nodule formation. It can occur at any age, has significant morbidity, and is an important cause of premature death. In addition, it is the most common cause of portal hypertension and its complication. The most common cause of liver cirrhosis is chronic viral hepatitis and prolonged excessive alcohol consumption worldwide.

What Are the Symptoms of Liver Cirrhosis?

Some patients do not display any symptoms, but some patients present the following symptoms:

• Enlarged liver (hepatomegaly).

• Enlarged spleen (splenomegaly).

• Weakness.

• Fatigue.

• Muscle cramps.

• Weight loss.

• Loss of appetite.

• Nausea and vomiting.

• Upper abdominal discomfort.

• Jaundice.

• Shortness of breath.

• Hair loss.

• Impotence.

• Variceal bleeding.

What Is Acute Gastric Cardiofundal Variceal Bleeding?

It is a gastrointestinal emergency. It is a life-threatening condition and needs urgent medical intervention. The morbidity rate of patients admitted to the hospital is about 10 percent. The gastro varices are of different types, and bleeding in the cardiac fundus region is called cardio-fundal variceal bleeding. The patient with variceal bleeding suffers from anemia, the passage of dark stools, blood in stools, and blood in vomiting. Severe acute upper gastrointestinal bleeding can sometimes cause maroon or bright red stool. In addition, esophagitis (inflammation of the food pipe), peptic ulcer, varices, cancer of the stomach, and liver cirrhosis cause acute upper gastrointestinal bleeding.

What Are the Treatment Options for Acute Variceal Bleeding?

• The main goal in the management of acute variceal bleeding is to restore circulation with blood and plasma, as shock reduces liver blood flow and causes further deterioration of liver function.

• The source of bleeding should always be confirmed by endoscopy because about 20 percent of patients bleed from the non-variceal region.

• All patients with cirrhosis and gastrointestinal bleeding should receive prophylactic broad-spectrum antibiotics, such as oral Ciprofloxacin or intravenous Cephalosporin or Tazobactam because sepsis is common, and treatment with antibiotics improves the outcome.

• The measures to control acute variceal bleeding include vasoactive medications (Terlipressin), endoscopic therapy (banding or sclerotherapy), balloon tamponade, transjugular intrahepatic portosystemic shunt, and rarely esophageal transection.

What Is Endoscopic Variceal Obturation?

Endoscopic variation obturation (EVO) is the most widely used initial treatment and is undertaken, if possible, at the time of diagnostic endoscopy. It stops variceal bleeding in 80 percent of patients and can be repeated if bleeding reoccurs.

This procedure includes band ligation. The process involves the varices being sucked into the cap placed on the end of the endoscope, allowing them to be occluded with a tight rubber band. Occluded varix subsequently sloughs with variceal obliteration. Banding is repeated every two to four weeks until all varices are obliterated. Regular follow-up endoscopy is required to identify and treat any recurrence of varices. Band ligation has fewer side effects than sclerotherapy. This is a technique in which varices are injected with a sclerosing agent and has largely replaced it. Banding is best suited for the treatment of esophageal varices. There is a lower risk of associated esophageal perforation than sclerotherapy.

What Is Retrograde Transvenous Obliteration?

Retrograde transvenous obliteration (RTO) refers to balloon-occluded retrograde transvenous obliteration. This technique employs a Sengstaken-Blackmore tube, consisting of two balloons that exert pressure in the stomach's fundus and lower esophagus, respectively. The line should be passed through the mouth, and its presence in the stomach should be checked by auscultating the upper abdomen while injecting air and confirming with radiology. The safest technique is to inflate the balloon in the gut under direct endoscopic vision. Gentle traction is essential to maintain the pressure on the varices. Initially, only the gastric balloons should be inflated with 200 ml (milliliter) to 250 ml of air as this will usually control bleeding. Tension in the esophageal balloon should be monitored with the sphygmomanometer and should not exceed 40 mm Hg. Balloon tamponade will almost always stop esophageal and gastric fundal variceal bleeding. Self-expanding removable esophageal stents are a new alternative for patients with bleeding esophageal but not gastric varices.

What Are the Effects of Endoscopic Variceal Obturation and Retrograde Transvenous Obliteration for Acute Gastric Cardio-fundal Variceal Bleeding?

Various experiments and previous studies compared the effect of endoscopic variceal obturation (EVO) and retrograde transvenous obliteration (RTO) in acute cardio-fundal variceal bleeding. Patients were separately treated with endoscopic variceal obturation (EVO) and retrograde transvenous obliteration (RTO) procedure. The patients were divided into the EVO and the RTO groups, respectively. The experiment results showed that:

1) Treatment Outcome -

• The outcome for the patients who undergoes endoscopic variceal obturation (EVO) and retrograde transvenous obliteration (RTO) are positive. The procedure helped control bleeding, and the patient was treated for complications.

• All patients who underwent EVO and RTO were followed up until death.

• The baseline characteristic was almost identical for the EVO and RTO groups. The mean model for end-stage liver disease scored higher in the EVO group than the RTO Group.

2) All Varices Rebleeding -

• The cardio-fundal varices bleeding control rate are the same in both EVO and RTO groups.

• Further observation showed that the rate of all variceal rebleeding is higher in the EVO group than in the RTO group.

• Rebleeding was defined as recurrent bleeding after an absence of bleeding for at least five days of acute gastro-variceal bleeding.

• The gastric variceal bleeding rate was also higher for the EVO group than for the RTO group.

3) Mortality Rates -

• During follow-up after the treatment, it was observed that the patient died due to variceal bleeding, infection, or liver failure.

• The survival rate for liver transplantation in both the EVO and RTO groups is the same.

• So, the mortality rates were similar for both groups.

Conclusion

No recent development in the treatment for acute cardio fundal variceal bleeding has been cited. In this comparison, all variceal and gastro-variceal bleeding rates are significantly higher for the EVO group than the RTO group. Studies state that the endoscopic variation obturation and retrograde transvenous obliteration effectively control bleeding. The complication rates are low for both groups with the same mortality rate. This study showed that both endoscopic variation obturation and retrograde transvenous obliteration treatment are safe and effective. It can be performed in acute cardio-fundal variceal bleeding. Retrograde transvenous obliteration was superior to endoscopic variation obturation in preventing variceal and gastro-variceal bleeding with the same mortality rates.